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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules-and Regulations of the San Joaquin <br /> Local Health District, <br /> r <br /> r - Cit 4 PM <br /> Lot Size . <br /> Job Address ` <br /> 32.11 <br /> ] � f�C,Gt-/`-� ,' Phone <br /> Owrler's Name <br /> Address <br /> i License.No 7 <br /> _Z(P Phone Vy_� <br /> Contract 7 Address - <br /> TYPE OF WELL/PUMP: NEW-WELL ❑ WELL REPLACEMENT O------��---DESTRUCTION ❑ <br /> ! PUMP INSTALLATION ID SYSTEM REPAIR CI OTHER ❑ <br /> �`� �---_� "'� "' DISPOSAL FLD� PROP. LINE <br /> # DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 1011 <br /> FOUNDATION AGRICULTURE WELL, .t a '"J OTHER-WEE PITS/SUMPS <br /> r s_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '1 <br /> ❑ Industrial ❑ Open Bottom 171-Manteca) of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack LITracy *`Type:af Casing Specifications <br /> I`1 Public [1 Other Cl Delta be pth"of Grout Seal Type of Grout <br /> I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Wotk Done O Type of Pump 'H.P. State Work Done <br /> I Well Destruction fl Well Diameter ., sealing Materia! Stop 50'1 <br /> f Depth R""` Fill6(Material IBelow 501 <br /> TYPE OF SEPTIC WORK: -NEW-INSTALLATION REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is. <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other f <br /> Number of living units: _J_ Number of be ms <br /> Character of soil tb,a depth of 3 feet: Water table depth <br /> �- SEPTIC TANK � Type/Mfg C Capacity � No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well f�o Foundation �� Property Line <br /> LEACHING LINE No. & Length of lines H0 Total length/size <br /> X <br /> r <br /> FILTER BED ❑ Distance to nearest: Well� � Foundation�( _. Property Line <br /> ' SEEPAGE PITS Depth r Size � ± _ Number <br /> SUMPS '` 0 'Distance to nearest: Well Foundation Property Line 15 <br /> DISPOSAL PONDS' "❑ <br /> I hereby certify that! have prepared this application and that the work will be done in accordance with San Joaquin county.ordinances, state laws, and <br /> rules and regulations-of the San Joaquin Local Health Diltrict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, !shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m call for aqui d inspections. Complete drawing on revers side. <br /> Signed X Title: #J'} Date:. <br /> FOR DEPART ENT USE ONLY <br /> �A plication Accepted by t = Date Area b <br /> Pi or GroutInspection by� Da Final Inspection I: Date <br /> dditional Comments: <br /> t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca. 823-7104 Q Tracy 835-6385 <br /> Applicant - Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., <br /> CA 95dPERMIT'NO. <br /> FEE ' AMOUNT DUE AMOUNT REMITTED CK V CASH RECEIVED BY DATE <br /> INFO <br /> +.EH13-24(REV.1/85) W n <br /> EH 14-28 <br />